- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,740.00 / $3,184.20 / $4,298.67
| Facility | | $1,740.00 | $3,184.20 | $4,298.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.60 / $1,374.60 / $1,374.60
| Professional | | $1,374.60 | $1,374.60 | $1,374.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.00 / $32.00 / $32.00
| Facility | | $32.00 | $32.00 | $32.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.00 / $32.00 / $32.00
| Professional | | $32.00 | $32.00 | $32.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,131.00 / $1,131.00 / $1,187.55
| Facility | | $1,131.00 | $1,131.00 | $1,187.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $40.00
| Professional | | $17.00 | $20.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.80 / $1,044.00 / $2,610.00
| Professional | | $730.80 | $1,044.00 | $2,610.00 |